A reduction in unnecessary expendi- tures contributing to rising health care costs 1,2 is essential in the judicious alloca- tion of health care dollars. The PricewaterhouseCoopers’ Health Research Institute defines waste as costs that could have been avoided without a negative impact on quality. 3 One major source of waste (estimated at $312 bil- lion/year) is providing services that are of no proven benefit. Of the $989 billion spent on health care in the US in 1995, ex- penditures for hospital care amounted to approximately $350 billion and constitut- ed the largest portion. 4 Assuming that in- tensive care unit (ICU) costs were 20% of all hospital costs, which they were esti- mated to be in 1986, these costs were around $70 billion in 1995 or 1% of the gross domestic product. 4 The high cost of intensive care is reflected in daily ICU costs, which range from $2000 to $3000 in many US hospitals. 5 In addition, more than one third of the pharmacy’s budget is spent in the ICU. 6 Thus, the ICU repre- sents a key site for resource optimization. Adequate sedation and analgesia, as well as treatment of anxiety and agitation, are important components of ICU care. Prolonged or excessive sedation may be detrimental. It has been linked to increased delirium occurrence, prolonged mechani- cal ventilation (MV), and decreased sur- The Annals of Pharmacotherapy ■ 2012 January, Volume 46 ■ 21 I-SAVE Study: Impact of Sedation, Analgesia, and Delirium Protocols Evaluated in the Intensive Care Unit: An Economic Evaluation Don-Kelena Awissi, Cindy Bégin, Julie Moisan, Jean Lachaine, and Yoanna Skrobik theannals.com Critical Care Author information provided at end of text. BACKGROUND: Intensive care units (ICUs) account for considerable health care costs. Adequate pain and sedation management is important to clinical care. OBJECTIVE: To determine whether implementing a protocol for management of analgesia, sedation, and delirium in the ICU would save costs. METHODS: With data from the I-SAVE (Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: an Economic Evaluation) study, a prospective pre- and postprotocol design was used. Between the 2 periods, protocols for systematic management of sedation, analgesia, and delirium were implemented. Cost-effectiveness was calculated by associating the variation of cost and effectiveness measures (proportion of patients within targeted pain, sedation, and delirium goals). Total costs (in 2004 Canadian dollars), by patient, consisted of the sum of sedation, analgesia, and delirium drug acquisition costs during the ICU stay and the cost of the ICU stay. RESULTS: A total of 1214 patients, 604 in the preprotocol group and 610 in the postprotocol group, were included. The mean (SD) ICU length of stay and the duration of mechanical ventilation were shorter among patients of the postprotocol group compared with those of the preprotocol group (5.43 [6.43] and 6.39 [8.05] days, respectively; p = 0.004 and 5.95 [6.80] and 7.27 [9.09] days, respectively; p < 0.009). The incidence of delirium remained the same. The proportion of patients with Richmond Agitation and Sedation (RASS) scores between –1 and +1 increased from 57.0% to 66.2% (p = 0.001), whereas the proportion of patients with a numeric rating scale (NRS) score of 1 or less increased from 56.3% to 66.6% (p < 0.001). The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to $5279.90 (6263.91) in the postprotocol group (p = 0.022). The cost analyses for pain and agitation management improved; the proportion of patients with RASS scores between –1 and +1 or NRS scores of 1 or less increased significantly in the postprotocol group while costing, on average, $932.74 less per hospitalization. CONCLUSIONS: Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization. KEY WORDS: analgesia, cost analysis, critical care, delirium, intensive care, pharmacoeconomics, sedation. Ann Pharmacother 2012;46:21-8. Published Online, 27 Dec 2011, theannals.com, DOI 10.1345/aph.1Q284 by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from by guest on October 11, 2013 aop.sagepub.com Downloaded from